Skill 16-7

Changing the Dressing and Flushing Central Venous Access Devices

Central venous access devices (CVADs) are venous access devices in which the tip of the catheter terminates in the central venous circulation, usually in the lower one third of the superior vena cava near its junction with the right atrium (Gorski et al., 2021). Types of CVADs include peripherally inserted central catheters (PICCs) (Figure 1), nontunneled percutaneous central venous catheters (Figure 2), tunneled percutaneous central venous catheters (Figure 3), and implanted ports. (Refer to Skill 16-8, Figure 1.) CVADs provide access for a variety of IV fluids, medications, blood products, and PN solutions and provide a means for hemodynamic monitoring and blood sampling. The use of a CVAD should be considered when the anticipated duration of infusion therapy is >15 days (Gorski et al., 2021). The type and duration of infusion therapy, patient preference, the patient's physiologic condition (age, health problems, comorbidities), and the patient's vascular condition (history of vascular access attempts, vessel, and skin health at potential insertion sites) determines the type of CVAD used (Gorski et al., 2021).

Maintenance of an intact and patent dressing in combination or integrated with a securement device at the insertion site is an important means of preventing infection, protecting the site, and promoting skin health and CVAD securement (Gorski et al., 2021). Transparent semipermeable membrane (TSM) dressings are commonly used to protect the insertion site. TSM dressings (e.g., Tegaderm™ or OpSite IV™) allow easy inspection of the site and permit evaporation of moisture that accumulates under the dressing. Sterile gauze may also be used to cover the catheter site. A gauze dressing is recommended if the patient is diaphoretic, or if the site is bleeding or oozing or has drainage from the exit site; replace it with a TSM once this is resolved (Gorski, 2020; O'Grady et al., 2017). Chlorhexidine-impregnated dressings are recommended for use as VAD site dressings for certain patient populations, including oncology patients with implanted ports, adult patients with short-term nontunneled CVADs, and patients with an epidural access device (Gorski et al., 2021). Site care and dressing changes are performed using aseptic nontouch technique to minimize the possibility of contamination when changing these dressings (ANTT) (Gorski et al., 2021). In the nontouch technique, the practitioner touches a site or equipment only as absolutely necessary, even when wearing sterile gloves (Taylor et al., 2023).

Facility policy generally determines the type of dressing and the intervals for dressing change. Perform site care and replace TSM dressings at least every 7 days (except neonatal patients) or immediately if the dressing becomes damp, loosened, visibly soiled, or has a lifted/detached border; blood or drainage is present; or there is compromised skin integrity under the dressing (Gorski et al., 2021). Change sterile gauze dressings at least every 2 days, or if the integrity of the dressing is disrupted (damp, loosened, visibly soiled) (Gorski et al., 2021). Consider the use of sterile adhesive removers and skin barrier film to prevent medical adhesive-related skin injury (MARSI) (Fumarola et al., 2020; Gorski et al., 2021; Zhao et al., 2018). Tunneled, cuffed CVADs may require a site dressing when the subcutaneous tunnel is healed (Gorski et al., 2021).

CVADs used for intermittent infusions should be flushed with preservative-free 0.9% sodium chloride solution and aspirated for a blood return prior to each infusion to assess catheter function (Gorski et al., 2021). Flushing of the device is also required after each infusion to clear the infused medication or other solution from the catheter lumen. CVADs should be locked with either a heparin solution (10 units/mL) or preservative-free 0.9% sodium chloride after each intermittent use, according to the directions for use for the specific CVAD and needleless connector (Gorski et al., 2021). If the device is not in use, periodic flushing according to facility policy is required to keep the catheter patent. Antimicrobial locking solutions are sometimes used in specific situations, such as with patients with long-term CVADs or in high-risk patient populations (Gorski et al., 2021).

Delegation Considerations

The changing of a CVAD dressing is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, the changing of a CVAD dressing may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Sterile tape or sterile adhesive skin closure strips (i.e., Steri-Strips™)
TSM dressing; antimicrobial dressing; or gauze pad for dressing, based on patient circumstances and facility policy
Several 2 × 2 gauzes
Sterile towel or drape
Cleansing swabs (>0.5% chlorhexidine in alcohol solution preferred [Gorski et al., 2021; Sarani et al., 2018]); if there is a contraindication to alcoholic chlorhexidine solution, tincture of iodine, an iodophor (povidone-iodine), or 70% alcohol may also be used (Gorski et al., 2021; Mimoz et al., 2015; O'Grady et al., 2017). Use chlorhexidine with caution in infants up to age 14 days, premature infants, and low-birth-weight infants due to the risk of skin irritation and chemical burns (Gorski et al., 2021)
Prefilled commercially prepared syringes with 10-mL sterile normal saline for injection (minimum volume equal to twice the internal volume of the catheter system) (Gorski et al., 2021); one for each lumen of the CVAD
Prefilled commercially prepared syringes with heparin 10 units/mL in 10-mL; one for each lumen of the CVAD (based on the manufacturer's directions for the use of the CVAD and needleless connector, and facility policy)
Masks (2), depending on facility policy
Gloves
Sterile gloves
Additional PPE, as indicated
Adhesive remover
Skin protectant/barrier wipe (e.g., Skin-Prep™)
Antimicrobial wipes
Needleless connector or positive pressure end caps; one for each lumen of the CVAD
Passive disinfection caps (based on facility policy)
IV securement/stabilization device, as appropriate
Sterile measuring tape
Bath blanket
Additional PPE, as indicated

Assessment

Assess the CVAD site. The CVAD site should be assessed with each infusion and at least daily in patients being treated in inpatient and nursing facility settings (Gorski et al., 2021). In community-care settings, the CVAD should be assess at every visit, and the patient or caregiver should be taught to check the CVAD site with each infusion or at least once per day (Gorski et al., 2021). The dressing should be intact, adhering to the skin on all edges. Check for any leaks or fluid under or around the dressing or other indications that the dressing needs to be changed. Inspect the tissue around the entry site for redness, swelling, tenderness, and warmth. These signs might indicate the development of localized infection. Ask the patient if they are experiencing any pain or discomfort related to the VAD, paresthesias, numbness, or tingling. Pain or discomfort can be a sign of infiltration, extravasation, phlebitis, thrombophlebitis, deep vein thrombosis, and/or infection. Refer to Fundamentals Review 16-3. Note the insertion date/access date and the date of the last dressing change. Assess the patient's need to maintain the CVAD. If the patient does not need the access, discuss the possibility of discontinuation with the health care team. Evaluate the patient's history for any allergies or sensitivity to skin antiseptics (Gorski et al., 2021). Assess the patient's knowledge of CVAD therapy. Assess the CVAD condition. Verify if the current locking solution dwelling in the CVAD needs to be aspirated and discarded or may be infused as part of the flushing procedure; all antimicrobial lock solutions must be aspirated and discarded (Gorski et al., 2021).

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Infection risk
Knowledge deficiency
Altered skin integrity risk

Outcome Identification and Planning

The expected outcomes to achieve when changing a dressing and flushing a CVAD are that site care is provided, and the dressing is changed and the device is flushed without adverse effect. In addition, the patient exhibits an access site that is clean, dry, and without evidence of any signs and symptoms of infection or other adverse effect, and the CVAD remains patent.

Implementation

Action	Rationale
1. Assess and discuss with the health care team the need for continued CVAD access. Determine the need for a dressing change. Check facility policy. Often, the procedure for CVAD flushing and dressing changes will be a standing protocol. Gather equipment.	The clinical need for the CVAD should be assessed on a daily basis in acute inpatient settings and during regular assessment visits in community-based care settings (Gorski et al., 2021). The particular facility's policies determine the type of dressing used and when these dressings are changed. Dressing changes might be required more often, based on nursing assessment and judgment. Immediately change any dressing that is damp, loosened, visibly soiled, or has a lifted/detached border; blood or drainage is present; or if there is compromised skin integrity under the dressing (Gorski et al., 2021). Preparation promotes efficient time management and an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. Unclean hands and improper technique are potential sources for infecting a CVAD. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the bedside stand or overbed table or other surface within reach.	Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
5. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why. Ask the patient about allergies to tape and skin antiseptics.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement. Possible allergies may exist related to the tape or antiseptics.
6. Place a waste receptacle or bag at a convenient location for use during the procedure.	Having a waste container handy means the soiled dressing can be discarded easily, without the spread of microorganisms.
7. Adjust the bed to a comfortable working height (VHACEOSH, 2016).	Having the bed at the proper height prevents back and muscle strain.
8. Assist the patient to a comfortable position that provides easy access to the CVAD insertion site and dressing. If the patient has a PICC, position the patient with their arm extended from the body below heart level. Use the bath blanket to cover any exposed area other than the site.	Patient positioning and use of a bath blanket provide for comfort and warmth. This position is recommended to reduce the risk of air embolism.
9. Apply a mask. Ask the patient to turn their head away from the access site. Alternatively, have the patient put on a mask, depending on facility policy. Move the overbed table to a convenient location within easy reach. Set up a sterile field on the table. Open the dressing supplies and add them to the sterile field. If IV solution is infusing via CVAD, interrupt it and place it on hold during dressing change. Apply the slide clamp on each lumen of the CVAD.	Masks help to deter the spread of microorganisms. The patient should wear a mask if they are unable to turn their head away from the site or based on facility policy. Many facilities have all sterile dressing supplies gathered in a single package. Stopping infusion and clamping each lumen prevents air from entering CVAD.
10. Put on clean gloves. Alternatively, use sterile gloves if there is a need to touch the insertion site (Gorski et al., 2021). Assess the CVAD insertion site through the old dressing (Figure 4). (Refer to previous Assessment discussion.) Palpate the site, noting pain, tenderness, or discomfort. Stabilize the catheter by holding it in place with your nondominant hand and support the skin. Beginning at the device hub, gently lift the edge of the dressing away from the skin, then gently push the skin down and away from the dressing/adhesive (Fumarola et al., 2020). Lift the dressing perpendicular to the skin toward the insertion site, carefully removing the old dressing and/or stabilization/securing device. If the patient is at increased risk for medical adhesive-related skin injury (MARSI), or there is resistance, use an adhesive remover (Barton, 2020; Fumarola et al., 2020; Kelly-O'Flynn et al., 2020). Avoid inadvertently dislodging the CVAD, as it may be adhered to the dressing/stabilization device (Gorski et al., 2021). Discard the dressing.	Gloves prevent contact with blood and body fluids. Pain, tenderness, or discomfort on palpation may be a sign of infection. The catheter/needle may be adhered to the dressing, increasing the risk of accidental dislodgment. Pushing the skin down and away from the adhesive reduces the risk for medical adhesive-related skin injury (MARSI) (Fumarola et al., 2020). Rapid and/or vertical pulling or insufficient support of skin when removing the dressing should be avoided (Gorski et al., 2021). The use of adhesive remover allows for the easy, rapid, and painless removal without the associated problems of skin stripping and helps reduce patient discomfort (Barton, 2020; Fumarola et al., 2020; Kelly-O'Flynn et al., 2020). Proper disposal of dressing prevents transmission of microorganisms.
11. Based on the device in use, remove the stabilization device according to the manufacturer's directions. Securement devices designed to remain in place for the life of the CVAD (e.g., a subcutaneous anchor securement system) does not need to be removed and replaced regularly with each dressing change but should be assessed during site care to ensure its integrity (Gorski et al., 2021). Remove your gloves and discard them.	The stabilization device is changed with the dressing change, based on the manufacturer's directions (Gorski et al., 2021). Removing gloves properly reduces the risk for infection transmission and contamination of other items.
12. Perform hand hygiene. Put on sterile gloves. Starting at the insertion site and continuing in a circle, wipe off any old blood or drainage with a sterile antimicrobial wipe. Use a single-use sterile applicator containing sterile antiseptic solution to cleanse the site with >5% chlorhexidine in alcohol solution or the solution identified in facility policy, making sure to cover, at minimum, the area to be covered with the dressing. Follow the manufacturer's directions for use to determine product application process and dry times (Gorski et al., 2021). Allow the antiseptic to dry naturally; do not wipe, fan, or blow on the skin (Gorski et al., 2021).	Hand hygiene prevents transmission of microorganisms. Site care and replacement of the dressing are accomplished using sterile ANTT technique. Cleansing is necessary because organisms on the skin can be introduced into the tissues or the bloodstream with the needle. Use of >0.5% chlorhexidine in alcohol solution is preferred for skin antisepsis (Gorski et al., 2021; Sarani et al., 2018). If there is a contraindication to alcoholic chlorhexidine solution, tincture of iodine, an iodophor (povidone-iodine), or 70% alcohol may instead be used (Gorski et al., 2021; Mimoz et al., 2015; O'Grady et al., 2017).
13. Apply antimicrobial dressing (chlorhexidine-impregnated) at the insertion site, based on facility policy (Figure 5). Apply the skin protectant to the same area, avoiding direct application to the antimicrobial dressing or the insertion site, and allow it to dry. Apply the securement/stabilization device, if used, and/or the TSM dressing, centering it over the insertion site (Figure 6). Measure the external CVAD length and compare it to the external CVAD length documented at insertion.	Use chlorhexidine-impregnated dressing for all patients ages 18 years and older with short-term nontunneled CVADs (Gorski et al., 2021). Skin protectant under the antimicrobial dressing interferes with the action of the dressing. Skin protectant improves adhesion of the dressing and protects the skin from damage and irritation when the dressing is removed. The TSM dressing allows easy visualization and protects the site. Stabilization/securing devices preserve the integrity of the access device, minimize catheter movement at the hub, and prevent catheter dislodgement and loss of access (Gorski et al., 2021). Some stabilization devices also act as a site dressing. Measurement of the extending catheter can be compared with the documented length at the time of insertion to assess if the catheter has migrated inward or moved outward (Gorski et al., 2021).
14. Based on facility policy, replace the end caps/needless connection devices, as indicated. Working with one lumen at a time, remove the needleless connector or end cap. Using an antimicrobial swab, vigorously disinfect the connection surface and sides of each access site and allow it to dry. Attach a new needleless connector or end cap. Repeat for each lumen.	Change the needleless connectors no more frequently than at 96-hour intervals or according to the manufacturer's directions for use; changing more frequently adds no benefit and has been shown to increase the risk of catheter-associated blood stream infections (Gorski et al., 2021). VAD administration set entry points, end caps, and needleless connectors must be vigorously scrubbed and disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent VAD-related infection (Frimpong et al., 2015; Gorski et al., 2021; Harper, 2014; Loveday et al., 2014). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely to ensure complete effectiveness. Passive disinfection caps contain an antiseptic-impregnated sponge that dispenses the antiseptic over the connector's top and threads and protects the hub from contamination by touch or airborne sources (Gorski et al., 2021; Stango et al., 2014).
15. If required, flush each lumen of the CVAD. The amount of saline and heparin flushes varies depending on the specific CVAD and on facility policy.	Flushing maintains patency of the CVAD.
To Flush the Lumen(s) 16. Using an antimicrobial swab, vigorously scrub the needleless connector or end cap on one of the lumens and allow it to dry. Prevent connection/disconnection reflux by using the appropriate sequence for flushing, clamping, and disconnecting determined by the type of needleless connector being used (Box 16-4 in Skill 16-5) (Gorski et al., 2021). Insert the saline flush syringe into the needleless connector. Open the clamp on the lumen. Slowly inject the saline flush, noting any resistance or sluggishness, and slowly pull back on the syringe to aspirate for positive blood return. If positive, instill the remaining solution over 1 minute or by using a pulsatile flushing technique of 10 short boluses of 1 mL interrupted by brief pauses; flush the line according to facility policy. Remove the syringe. Insert the locking solution syringe and instill the volume of solution designated by facility policy over 1 minute or according to facility policy. Remove your gloves. Perform hand hygiene.	VAD administration set entry points, end caps, and needleless connectors must be disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent VAD-related infection (Frimpong et al., 2015; Gorski et al., 2021; Harper, 2014; Loveday et al., 2014). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely following the manufacturer's directions for use (Gorski et al., 2021). The action of the positive pressure end cap is maintained with the appropriate sequence for flushing, clamping, and disconnecting determined by the type of needleless connector in use (Gorski et al., 2021). The presence of a blood return upon aspiration and lack of resistance when flushing indicate patency of the VAD (Gorski et al., 2021). Flushing maintains patency of the IV line. A pulsatile flushing technique of 10 short boluses of 1 mL interrupted by brief pauses may be more effective in removing solid deposits (e.g., fibrin, drug precipitate, intraluminal bacteria) (Gorski et al., 2021). Clamping prevents air from entering the CVAD. Vascular access devices are locked after completion of the flush solution at each use to decrease the risk of occlusion (Gorski et al., 2021). CVADs should be locked with either a heparin solution (10 units/mL) or preservative-free 0.9% sodium chloride after each intermittent use, according to the directions for use for the specific CVAD and needleless connector (Gorski et al., 2021). Removing gloves properly and hand hygiene reduce the risk for infection transmission and contamination of other items.
17. Using an antimicrobial swab, vigorously disinfect the connection surface and sides of each access site and allow them to dry. Attach a passive disinfection cap to each access site (Figure 7).	Passive disinfection caps contain an antiseptic-impregnated sponge that dispenses the antiseptic over the connector's top and threads and protects the hub from contamination by touch or airborne sources (Gorski et al., 2021; Stango et al., 2014). VAD administration set entry points, end caps, and needleless connectors must be vigorously scrubbed and disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent VAD-related infection (Frimpong et al., 2015; Gorski et al., 2021; Harper, 2014; Loveday et al., 2014). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely to ensure complete effectiveness.
18. Label the dressing with the date, time of change, and your initials. Resume fluid infusion, if indicated. Check that the IV flow is accurate and the system is patent. (Refer to Skill 16-2.)	Other personnel working with the infusion will know what type of device is being used, the site, and when the dressing was last changed.
19. Apply an IV securement/stabilization device if not already in place as part of the dressing, as indicated, based on facility policy. Explain to the patient the purpose of the device and the importance of safeguarding the site when using the extremity.	The weight of the tubing and/or tugging on the tubing could cause catheter dislodgement. These systems are recommended for use on all venous access sites, and particularly central venous access sites, to preserve the integrity of the access device, minimize catheter movement at the hub, and prevent catheter dislodgement and loss of access (Gorski et al., 2021). Some devices also act as a site dressing and may already have been applied.
20. Remove equipment. Ensure the patient's comfort. Lower the bed, if it is not in the lowest position.	Positioning promotes patient comfort and safety.
21. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when site care has been provided and the dressing has been changed and the device flushed without adverse effect. In addition, the patient has exhibited an access site that is clan, dry, and without evidence of any signs and symptoms of infection or other adverse effect, and the CVAD remains patent.

Documentation

Guidelines

Document the location, appearance, and condition of the CVAD site. Include the presence or absence of signs of erythema, redness, swelling, or drainage and the external CVAD length. Record whether the patient is experiencing any pain or discomfort related to the CVAD. Document the clinical criteria for site complications. Refer to Fundamentals Review 16-3 and Box 16-2 (in Skill 16-2). Record the patient's subjective comments regarding the absence or presence of pain at the site. Record the patient's reaction to the procedure and pertinent patient teaching, such as alerting the nurse if the patient experiences any pain from the site or notices any swelling at the site. The CVAD lumens should flush without difficulty. Communicate any abnormal findings, such as dislodgement of the CVAD, abnormal insertion assessment findings, or inability to flush the CVAD, to the health care team.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

While dressing is being changed, CVAD is inadvertently dislodged: Notify the health care team. If the CVAD is not all the way out, a chest x-ray may be prescribed to determine the location of the end of the CVAD. Reapply a dressing before the chest x-ray is completed so that the CVAD is not further dislodged.
When the dressing is removed, purulent drainage is noted at the insertion site: Obtain a culture of the site, clean the area, reapply a dressing, and notify the health care team. This prevents the CVAD from being open to air and unprotected while you are notifying the health care team. In addition, the culture is obtained without having to remove the dressing a second time. If a culture of the site is not prescribed, discard it in the appropriate receptacle.
When flushing the catheter, you are unable to withdraw blood, there is a sluggish flow, and/or you are unable to flush or infuse through the CVAD: These signs may indicate CVAD occlusion. Consult with the nurse IV team and the health care team for appropriate catheter clearance/repair procedures to preserve the function of the CVAD (Gorski et al., 2021).

Special Considerations

Use a 10-mL syringe or a syringe specifically designed to generate lower injection pressure to assess CVAD patency (Gorski et al., 2021).
The use of single-use, commercially prepared, prefilled syringes of appropriate solution to flush and lock VADs reduces the risk of catheter-associated bloodstream infection and saves time for syringe preparation (Gorski et al., 2021).
The minimum volume for 0.9% sodium chloride flush solution is the volume equal to twice the internal volume of the catheter system, the catheter plus add-on devices (Gorski et al., 2021).
If edema is present and/or upper extremity venous thrombosis is suspected in a patient with a PICC, measure the arm 10 cm above the antecubital fossa and compare the measurement with the documented measurement from the time of PICC insertion to confirm the presence of edema (Cicolini et al., as cited in Kline & Katrancha, 2019).
The continued need for PICCs and nontunneled CVADs should be assess on a daily basis and removed when there is a change in the patient's infusion needs, or it is no longer needed for the plan of care (Gorski et al., 2021).
The continued need for tunneled and implanted CVADs should be assessed on a regular basis; removal may be indicated when infusion therapy is completed, in the presence of an unresolved complication, or when it is no longer needed for the plan of care; consideration should be given to the possibility for infusion therapy to resume in the future (Gorski et al., 2021).
Use of >0.5% chlorhexidine in alcohol solution is preferred for skin antisepsis (Gorski et al., 2021; Sarani et al., 2018). If there is a contraindication to alcoholic chlorhexidine solution, tincture of iodine, an iodophor (povidone-iodine), or 70% alcohol may instead be used (Gorski et al., 2021; Mimoz et al., 2015; O'Grady et al., 2017).
Drying time with 70% isopropyl alcohol is 5 seconds; alcohol-based chlorhexidine requires 20 seconds. Povidone-iodine requires longer than 6 minutes to be thoroughly dry, making it less favorable to clinical practice (Gorski et al., 2021).
Chlorhexidine-impregnated dressings are recommended for use as VAD site dressings for certain patient populations, including oncology patients with implanted ports, adult patients with short-term nontunneled CVADs, and patients with an epidural access device (Gorski et al., 2021).
Heparin-induced thrombocytopenia (HIT) has been reported with the use of heparin flush solutions. Monitor all patients closely for signs and symptoms of HIT. If present or suspected, discontinue heparin (Gorski et al., 2021).
Use of topical antibiotic ointments or creams on insertion sites as part of routine site care is not recommended because of their potential to promote fungal infections and antimicrobial resistance (Gorski et al., 2021; O'Grady et al., 2017).
Do not submerge venous catheters and catheter sites in water; showering is permitted with the use of impermeable coverings (clear plastic wrap or a device designed for this purpose) to protect the catheter and connections (Gorski et al., 2021; O'Grady et al., 2017; York et al., 2020).

Infant and Child Considerations

Use chlorhexidine with caution in infants up to age 14 days, premature infants, and low-birth-weight infants due to the risk of skin irritation and chemical burns (Gorski et al., 2021).

Older Adult Considerations

Avoid using vigorous friction at the insertion site, which can traumatize fragile skin and veins in older adults.

Community-Based Care Considerations

In community-based settings, the CVAD should be assessed at every visit, and the patient or caregiver should be taught to check the CVAD site with each infusion or at least once per day (Gorski et al., 2021).
Patient and family/caregiver education should include managing activities of daily living (bathing, clothing, seatbelts) to prevent needle dislodgement, reporting any signs or symptoms of complications (pain, burning, stinging, or soreness), and follow-up actions (Gorski et al., 2021).

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Skill 16-7

EVIDENCE FOR PRACTICE